The Spiritual Needs of the Dying: Best Practices for ...



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|Daneker, D., & Smith, C. (2007). The spiritual needs of the dying: Best practices for professional counselors. Retrieved August 28, 2007, |

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|The Spiritual Needs of the Dying: Best Practices for Professional Counselors |

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|Darlene Daneker |

|Marshall University |

|Daneker, Darlene, Ph.D., is an Assistant Professor at Marshall University in the Graduate College Department of Counseling. She is |

|interested in researching grief, trauma, and developing ethics in counseling students. |

|Carol M. Smith |

|Marshall University |

|Smith, Carol M., MACE, Ph.D., is an Adjunct Professor at Marshall University in the Graduate College Department of Counseling.   Her |

|research interests include grief, trauma, and loss, and the cross-disciplinary intersection of biomedical ethics and counseling. |

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|Best Practices for Professional Counselors |

|Interest in spiritual aspects of counseling has grown significantly, as evidenced by an increase in relevant articles since September 2001.|

|  An EBSCO Host database search indicated that 108 articles on “spirituality and counseling” were published each year from September 2000 |

|to August 2002.  From September 2004 to August 2005, 254 articles were published; a 100% increase from the same time periods in 2000-2002. |

|  Even so, less than 25% of these articles specifically address spiritual needs during dying or death. The experience of death is the |

|epicenter of spirituality and has been cited as one reason for the existence of religion and spiritual beliefs (Axelrod, 1986, as cited in |

|Smith, 1993). |

|As interest in spirituality has increased in the professional literature, demographic trends in the United States similarly indicate a |

|growing need for information and understanding about death and the dying process. As a demographic force, members of the Baby Boom |

|generation--those born between 1946 and 1964 (Gillon, 2004)--have changed each life stage they have entered. While Boomers, as a whole, are|

|not currently considering their own deaths, many are now facing the decline and deaths of their parents.   “When 75 million people confront|

|an issue, it becomes culturally significant” (Rybarski, 2004). It is prudent for the counseling profession to be prepared to provide |

|competent guidance as an increasing number of people encounter the issue of dying, first for their parents and then for themselves |

|(Daneker, 2003). |

|The spiritual needs of the dying concerns professional counselors for two reasons.   First, both long-term care of the dying and |

|bereavement represent stressful and spiritually provocative situations for both the dying and their caregivers.   Second, because the rate |

|of death is expected to accelerate in the United States over the next 50 years, increasing numbers of people will experience these |

|spiritually challenging and emotionally difficult situations (Smith, 2003).   This demographic, combined with an increasing interest in |

|spirituality in the counseling literature, indicates that competence in understanding the spiritual needs of the dying will be helpful in |

|providing competent counseling to an enlarging clientele. |

|Spirituality and Dying |

|Existential theorists consider death as one of four ultimate concerns of life, along with personal isolation, meaning-making, and freedom |

|(Yalom, 1980).   The process of facing death   inextricably involves the other three concerns, most particularly the process of |

|meaning-making (Corr, Doka, & Kastenbaum, 1999; Frankl, 1992; Kinnier, Tribbensee, Rose & Vaughan, 2001; Kübler-Ross, 1975; Weisman, 1993; |

|Yalom, 1980).   According to existential theorists, life and death are continuously co-existent, intertwined with one another (Frankl, |

|1992; Heidegger, 1962; Kübler-Ross, 1975, Weisman, 1993; Yalom 1980).   Yalom (1980) wrote, “A confrontation with one’s personal death (‘my|

|death’) is the nonpareil boundary situation and has the power to provide a massive shift in the way one lives in the world’ (p. 159). |

|Experiencing the death of a loved one is frequently the first experiential encounter with the idea of “my death,” with a similar |

|existential impact.   “Recognition of death contributes a sense of poignancy to life, provides a radical shift of life perspective, and can|

|transport one from a mode of living characterized by diversions, tranquilization, and petty anxieties to a more authentic mode” (Yalom, p. |

|40). |

|Goals of Addressing Spiritual Needs of the Dying |

|The primary goal of addressing the spiritual needs of the dying is to provide appropriately comprehensive care for the whole person. To |

|address physical and emotional needs alone, but neglect the existential, meaningful components of the dying process, is to provide |

|incomplete and dissatisfying care to an individual who is confronted with the ultimate questions of life (Smith, 2003). As physical |

|symptoms, such as pain management, come under control, other dimensions of life become increasingly important (Byock & Merriman, 1998).   |

|The provision of comprehensive spiritual care for dying individuals includes seven goals: |

|Provide culturally sensitive care |

|Increase quality of life |

|Alleviate anxiety |

|Provide comfort and personal contact |

|Promote meaning, significance and hope |

|Promote informed decisions congruent with spiritual values |

|Increase caregiver confidence |

|Providing culturally sensitive care |

|Providing culturally sensitive care involves a respectful inquiry about the dying client’s belief system, past spiritual experiences, and |

|current spiritual needs.   “To use these [spiritual] conceptualizations with clients will require a comfort with the idea that there are |

|diverse ways of expressing spirituality by the many diverse peoples in the world” (Pate, 1992, as cited in Ingersoll, 1994).   Culturally |

|sensitive approaches to providing spiritual care by counselors includes thoughtful investigation of the client’s religious traditions, |

|personal spiritual development, and spiritual memories, such as memories of conversion experiences, of disillusionment experiences, and of |

|values inherited from ancestors and cultural history.   Consideration of how the client’s personal spirituality may differ from his or her |

|cultural history or traditional religious expectations may help the client achieve reconciliation and a sense of peace with his or her |

|upbringing. |

|Quality of life |

|Increasing quality of life through spiritual care of the dying includes providing the opportunity to discuss what one does and does not |

|want to happen in the way care is provided.   By giving clients the opportunity to talk about life in spiritual terms, the counselor adds |

|to the client’s understanding of what is happening currently, and what he or she would like to happen in the future.   The concept of a |

|psychologically “healthy” death (Smith, 1993) requires the active participation of clients to communicate their needs. For example, if a |

|client becomes aware of a need for confession or forgiveness when giving spiritual consideration of his or her current life, a counselor |

|can arrange for a consultation with the client’s spiritual leader (pastor, priest, shaman, rabbi, imam) to provide a culturally appropriate|

|ritual within the client’s religious tradition.   Likewise, whether the counselor promotes the calmness and quiet of a Buddhist death, or |

|provides for an opportunity to extend or receive forgiveness in a Christian death, each fulfills an important aspect of “seeking closure” |

|in one’s dying process (Byock, 1997). |

|Alleviating anxiety |

|Counselors can help dying clients reduce anxiety by helping them name their spiritual fears and concerns, by providing an opportunity to |

|speak about them openly, and by extending validation and support. Counselors’ work with dying clients can provide a way of coming to terms |

|with spiritual concerns through experiential methods such as guided imagery, artwork, poetry, religious ritual, breathing exercises, and |

|progressive desensitization. This experiential process is limited only by imagination and physical abilities.   Anything which the client |

|finds effective in alleviating anxiety can be considered in the clinical encounter. |

|Provide comfort and personal contact |

|By providing comfort and personal contact, the counselor provides the dying client a safe environment in which to consider spiritual |

|aspects of the dying process.   The counselor, by spending time in conversation with a dying client provides an important function for that|

|client, in that the counselor bears witness to the client’s story, spirituality, meanings, memories, and values.   The accepting, |

|validating, personal contact provided by a counselor may be unique among the client’s circle of caregivers.   While other caregivers may be|

|pressed by their own anxieties or demanding schedules, the attentive presence of a counselor allows the client to feel accepted, to be |

|comforted, and to process spiritual needs without undue concern for the counselor’s welfare.   Bearing witness to the client’s situation |

|has profound spiritual implications because the client becomes aware that the counselor acts as a “container” for the client’s experience, |

|and that the counselor may carry those experiences into a future which does not include the client.   The opportunity to have one’s |

|experiences and spiritual values be remembered and validated can be a significant source of comfort for a dying client. |

|Promote meaning, significance and hope |

|By allowing the client time and space to process his or her story, the counselor provides an opportunity to discover a new sense of meaning|

|in the client’s experiences.   For example a client may report, “I have learned not to take things for granted, and to treasure even very |

|small acts of kindness.”   Processing the meaning of one’s death in a purposefully spiritual way allows the client to gain a sense of |

|personal significance, or an idea of where and how he or she belongs to a larger human story, whether in one’s immediate family, or in the |

|larger community.   A sense of hope may be achieved by considering the dying process in terms of one’s ultimate future, one’s legacy, or a |

|sense of significance in the meaning of one’s life and one’s relational effect on others (Daneker, 2005).   Counselors, through a |

|culturally sensitive process, can give clients the opportunity to discover and articulate a sense of meaning, significance, and hope by |

|giving clients the opportunity to discuss their dying process in spiritually specific terms, such as forgiveness, reconciliation, |

|acceptance, interpersonal relationships, and the client’s relationship with God, or the Infinite. |

|Promote informed decisions congruent with spiritual values |

|Counseling in a spiritually sensitive way can promote informed decisions which are congruent with clients’ spiritual values.   By |

|considering their spiritual values with a counselor, clients may become more aware of what they do and do not want to have happen during |

|their dying process.   Through thoughtful consideration of one’s spiritual values, decisions about advanced directives and medical powers |

|of attorney can be clarified.   For instance, a client’s spiritual acceptance of the dying process may guide an advanced directive to |

|refuse or accept further life-sustaining treatments, including food, water, and assisted respiration. |

|Increase caregiver confidence |

|Finally, by providing turnkey care to the client, the client’s family, and other concerned health care personnel, the counselor can |

|increase caregiver confidence that the client’s spiritual needs are being addressed throughout the dying process.   By helping the client |

|communicate to others his or her spiritual needs and desires we empower the client to educate others about his or her wishes. When |

|caregivers know that they are attending appropriately to the dying person’s spiritual needs, caregivers are assured that the most |

|existentially important aspects of the person’s care are being satisfied.   This reassurance may increase caregiver confidence that “we did|

|everything possible,” and caregivers may be less likely to feel guilt during bereavement that important needs went unattended.   |

|Furthermore, attending to the spiritual needs of the dying individual may provide caregivers a profound sense of peace and significance |

|about their caregiving; that they contributed meaningfully to the dying person’s last days. |

|Assessment |

|The counselor may prepare the client for a question about spiritual needs by distinguishing between religion and spirituality, and asking |

|the client to think of his or her spirituality in terms of personal growth, meaning, values, and desire for whatever the client’s belief |

|system holds after death.   A simple opening question might also be, “Do you have any unfinished business, spiritually?” Other important |

|questions to ask clients include “What do you hope for now, as you live with this diagnosis (condition, unwanted news, loss)?”, “What in |

|all of this do you fear the most?”, “What is left undone in your life?”, “How are things going now for you and your family?”, and “What are|

|you thinking about, in spiritual terms, as you consider your situation?” Questions like these open opportunities for discussions at deeper |

|levels of meaning for the client, and guide further treatment planning.   They give the client an opportunity to speak freely about things |

|which may have been withheld for fear of reprisal or abandonment.   Finally, Byock (1997) outlines the five “most important” statements |

|that dying people need to address: (a) I forgive you; (b) Please forgive me; (c) Thank you; (d) I love you; and (e) Good bye.   Structuring|

|sessions around these themes will help clients reach a sense of “closure” and preparedness for the dying process.   As these questions are |

|addressed with honor and compassion, clients may achieve an improved quality of life and inner peace as they consider their ultimate |

|concerns in life and death. |

|Other methods for assessing spiritual needs of dying clients can be used, including individualized checklists, open-ended conversations, |

|even discussion of clients’ artwork, and personal narratives (Neimeyer, Moser, & Wittkowski, 2003).   As ongoing assessment yields new |

|information, therapy and services can be adjusted accordingly, promoting continuity and quality of care on an individualized basis. |

|Best Practices |

|Elevate client’s experience over routine.   The notion that individual care of a dying person should be elevated over the demands of |

|day-to-day routine may seem axiomatic.   The reality is that the urgent demands of paperwork, scheduling, meetings, competing needs of |

|other clients, and even counselor burn-out may significantly interfere with the quality of client care.   The client’s experience should be|

|elevated above routine by demonstrated commitment to attending to the client’s needs.   This commitment is evidenced by providing adequate |

|time for increasingly frail or ill clients to tell their stories, express their feelings, and put words to their fears.   The commitment is|

|further evidenced by attention to detail, and personalized actions, such as sharing picture books with artistic clients, playing music to |

|the client’s liking, and asking clients to share thoughts and memories about photograph albums, personal belongings, and other “linking |

|objects” (Andrews & Marotta, 2005). Elevating the client’s experience over routine also entails appropriate attention to multicultural |

|concerns, such as the client’s family traditions, cultural values, important religious rituals such as confession, fasting, creation of |

|memorial altars, and anointing with oil. |

|Experiential therapies. In addition to traditional talk therapy about spiritual issues, counselors may also consider using the senses of |

|touch, hearing, taste, and smell in the co-creating (with the client) of healing experiences or spiritual rituals.   For example, a client |

|may find the feel of silk on her skin to be helpful in achieving a meditative state of being.   Or soothing instrumental music may help |

|calm a client after receiving distressing medical news.   Incense, oils, candles, and perfumes can be used as long as the client finds them|

|helpful, and as long as such things do not interfere with medical treatment, particularly oxygen therapy.   Anything which lends meaning |

|and significance to the client’s experience, and anything which provides a sense of comfort and support, should be considered for use in |

|experiential therapies with dying clients. |

|Educate client and caregivers.   Both clients and caregivers require ongoing education about what to expect in the dying process.   In |

|addition to questions about physiological changes they can expect, clients and caregivers alike will benefit from preparation about |

|psychological and emotional changes at the end of life, as well.   Such educational efforts on the counselor’s part will help clients to |

|know what to expect.   For example, clients and their caregivers may benefit from clear answers to specific questions such as, “Will I be |

|abandoned?,” “What will happen next?” “What is the actual dying process like?” and “How can I make the best use of my time now?”     |

|Conclusion |

|Counselors are wise to prepare for an increasing demand for spiritual care as clients age and confront death and dying.   As the Baby Boom |

|generation ages, approaches to client care in the dying process will change dramatically.  These approaches should include an attention to |

|culturally sensitive interventions, actions to alleviate anxiety if the anxiety is creating difficulty for the client, and on going |

|assessment of the client’s needs. Death and dying are anxiety provoking topics for anyone and counselors working with dying individuals |

|need to remain alert to their own defenses in confronting their own death. Attention to the counselor’s own death anxiety will help elevate|

|the care of the dying individual above the routine as well as promote self care and spiritual growth opportunities for the counselor. |

|References |

|Andrews, C. R, & Marotta, S.A. (2005). Spirituality and coping among grieving children: A preliminary study. Counseling and Values, 50(1), |

|38-50. |

|Byock,   I. R. (1997). Dying well: The prospect for growth at the end of life. New York: Putnam/Riverhead |

|Byock, I. R., & Merriman, M. P. (1998). Measuring quality of life for patients with terminal illness: The Missoula-VITAS quality of life |

|index. Journal of Palliative Medicine, 12, 231-244 |

|Corr, C. A., Doka, K. J., & Kastenbaum, R. (1999). Dying and its interpreters: A review of selected literature and some comments on the |

|state of the field. Omega, 39(4), 239-259. |

|Daneker, D. P. (2003). A practice analysis of clinical thanatologists. Dissertation Abstracts International, 64(A-1), p. 72. (UMI No. |

|3078178) |

|Daneker, D. P. (2005). Counselors working with the terminally ill. American Counseling Association Virtual Library.   Retrieved November 6,|

|2006, from . |

|Frankl, V. (1992). Man’s search for meaning (4 th ed.). (I. Lasch, Trans.). Boston: Beacon. (Original work published 1946). |

|Gillon, S. (2004).   Boomer nation: The largest and richest generation ever and how it changed America. New York: Free Press. |

|Heidegger, M. (1962). Being and time. New York: Harper & Row. |

|Ingersoll, R. E. (1994). Spirituality, religion and counseling: Dimensions and relationships. Counseling and Values, 38(2), 98-111. |

|Kinnier, R. T., Tribbensee, N.E., Rose, C. A., & Vaughan, S. M. (2001). In the final analysis; More wisdom from people who have faced |

|death. Journal of Counseling and Development, 79(2), 171-177. |

|Kübler-Ross, E. (1975). Death: The final stage of growth. Englewood Cliffs, NJ: Prentice-Hall. |

|Neimeyer, R. A., Moser, R. P., & Wittkowski, J. (2003). Assessing attitudes toward dying and death: Psychometric considerations. Omega, |

|47(1), 45-76. |

|Rybarski, M. (2004). Boomers after all is said and done: A generation that rewrites all the rules takes on death. American Demographics, |

|Vol 26(5), 32-34. |

|Smith, D. (1993). Exploring the religious-spiritual needs of the dying. Counseling and Values, 37(2), 71-77. |

|Smith, C. M. (2003). Effect of counseling self-efficacy, training, and previous bereavement on counselors' ability to cope with death.   |

|Dissertation Abstracts International 63(9-A), 3118.   (UMI No. 3064356) |

|Weisman, A. D., (1993). The vulnerable self: Confronting the ultimate questions. New York: Plenum. |

|Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books. |

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|VISTAS 2007 Online |

|As an online only acceptance, this paper is presented as submitted by the author(s).  Authors bear responsibility for missing or incorrect |

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